A 49-year-old previously healthy woman was admitted for evaluation of new-onset headaches.

Without an apparent precipitating factor such as head trauma, back trauma, or lumbar puncture, our patient experienced an incapacitating positional headache. The headache was worse on assuming a sitting or standing position and was relieved when supine or prone. There had been no response to analgesics including codeine. She then developed horizontal binocular diplopia. She had no fever, neck stiffness, cerebrospinal fluid (CSF) rhinorrhea, or upper extremity radicular complaints. Eventually, a brain magnetic resonance imaging (MRI) showed diffuse thickening of the pachymeninges with diffuse, nonnodular intense enhancement with gadolinium. She was initially erroneously suspected of having meningitis. When a lumbar puncture (LP) was attempted, she was told she had a “dry tap” and was referred for further evaluation.